Eye chart with first three lines starting with the large E at the top of the page.

Foolproof Functional Vision Assessment Template

Use this template to help you gather and write your FVAs!

Updated April 20, 2023; original post published October 25, 2019 Check out the updated FVA Template!

“I seriously hope I didn’t forget anything,” we find ourselves thinking as we walk away from an evaluation session. There are so many areas that we evaluate and assess as Teachers of the Visually Impaired (TVIs), that it can be overwhelming to make sure that we cover everything.

Furthermore, how do we communicate the results of our assessments in a clear, organized way? This Functional Vision Assessment (FVA) Template organizes the information that we collect into an easy-to-view report, so that we can pinpoint precisely which skills are in need of improvement, and collaborate to create SMART goals for our teams to target with students. It pulls inspiration, definitions and assessment requirements from the Wisconsin DPI Eligibility Criteria for Visual Impairment Evaluation Guide and ToAD: Tools for Assessment and Development of Visual Skills, and breaks the information down into several clearly labeled sections. Below is additional information about how to fill out the sections:

Student Information

Informational data about the student, school, guardians, assessor, and dates. 

Medical Information

Essential ocular information obtained from the optometrist or ophthalmologist. 

Visual Behaviors and Skills Screenshot of FVA that can be accessed with Google Docs on tablet, phone or computer, or printed and filled in by hand.

This table can be brought with the TVI to the evaluation sessions to fill out during observations and formal/informal testing (electronically via Google Docs or old-fashioned pen and paper). 

Should the evaluation require multiple sessions, it is easy to see at a glance what information is still needed and fill in the blanks of this table during each visit. Each skill is described in detail, which transforms the FVA report from “TVI-jargon” (a list of skills that are unfamiliar to most members of the evaluation team) to a list that can be interpreted and understood by everyone. 

The skills that are not relevant to the student can be deleted from the template to keep the report concise and custom. Additionally, skill areas can be added in as the TVI sees fit.

Expanded Core Curriculum

This table provides a space to report on each area of the Expanded Core Curriculum (ECC). Many educational teams are unaware of the ECC, so this table also serves as a clear way to outline and describe the areas considered by the TVI. 

Observations & Interviews

This information can be listed or described in paragraph format, however it is important to note that no evaluation is complete without thorough observations and interviews. 

Learning Media Assessment Results

This section of the FVA is where the information gained from the Learning Media Assessment (LMA) is inserted (more info on LMAs from Paths to Literacy). The National Reading Media Assessment (NRMA) can be a great resource for helping teams determine the best reading media for a student. The results table and summary can be placed under this section of the FVA. 

Classroom Implications

Based on observations, interviews, and information gained from evaluating the student’s skills, this section illustrates challenges in the classroom environment. It is especially helpful for classroom teachers and can be included in the Individualized Education Plan (IEP) if the student qualifies for services. 

Purpose for Testing and Eligibility

After the FVA is complete, the next step is to determine if the student qualifies for services based on DPI standards. The checkmarks or X’s can be deleted to indicate the areas that apply.  It is up to the evaluation team, with guidance from the TVI, to determine if a student would benefit from direct/consult services.

Summary of Assessment Results

The purpose of the summary is to provide the overall “takeaway message”. Ideally, it is easy to understand by all members of the evaluation team with baseline data that is relevant to goal setting and progress monitoring. Consider all of the information gathered throughout the FVA and highlight the skill areas that are in need of improvement, as well as the areas of strength. This section does not contain goals or recommendations, and can be inserted into the IEP. 


This is generally a list of accommodations, tools, strategies or ideas to increase the student’s access and success in school. This information typically makes it into the IEP if the student qualifies for services, or a 504 Plan. 


Some evaluations may require the TVI to add in additional sections, while others may require some sections to be omitted or simplified. For example, we wouldn’t include information about switch activity with a student who is taking honors calculus. 

Overall, this FVA Template was designed to ensure two things. First, that no skill or area is overlooked during the evaluation process. Second, that the information gathered is presented in a format that is consistent and easy to understand. Our teams are counting on us to enlighten them with our expertise and insights, so open up those Google Docs or print this Functional Vision Assessment (FVA) Template out and get started on those evaluations!

Assessment materials and crafting supplies for VI, including a variety of textures such as fur, foam, and silicone.

Description: Assessment materials and crafting supplies for VI, including a variety of textures such as fur, foam, and silicone. 


By cortneybraille

Back to Paths to Technology’s Home page

Collage of Foolproof FVA template
Dr. Luisa Mayer

Visual Acuity Testing, Part 1: History of Preferential Looking and Early Testing

Digital math: computer, tablet and calculator displaying charts and graphs

Using the Desmos Calculator with Sara Larkin

A page with a long written formula and a green pencil.

How to create an accessible formula sheet